The Problem with TMJ Surgery

I’ve been successfully treating TMJ disorders with conservative splint therapy, orthodontics, and reconstructive crown and bridge work for more than 25 years. During that time, I’ve encountered less than a handful of patients who could only be helped with joint surgery. I have, however, consulted with and treated dozens of patients who have been plagued with continuing pain and the inability to chew correctly following TMJ surgery on one or both joints.

Unlike splint therapy, orthodontics, and reconstructive crown work which all focus on gently encouraging the joints to find a better position on their own through repositioning the way the teeth fit together, joint surgery often physically forces the TMJs into a completely new anatomical position. There is no ability for the joint to ease back and forth between positions or make the minute adjustments so often required to adapt to the constantly changing landscape of the mouth. The joint is simply moved or shaved, and there is no way for it to move back if the new position is not ideal.

Forcibly moving the joint with surgery may help create more room for the disc to move freely and correctly, resolving pain and functional issues associated with locking and popping, but surgery almost never takes into consideration the most important function of the jaw: making the teeth fit together for chewing. Too often, I have heard clients recount stories of being told to simply stop chewing and stay on a soft diet for the rest of their lives when their teeth no longer fit together after TMJ surgery. A long-term soft or liquid diet is not ideal for anyone, nutritionally or otherwise. And for a person in their 30s, 40s, or 50s? Never chewing again is simply not a good enough answer.

Unfortunately, the inability to chew is not the only potential negative outcome of TMJ surgery. Some patients experience recurrence of pain symptoms, locking, and popping within a few years after the surgery. The most unfortunate cases I see are in patients who undergo surgery and then end up in the same pattern of symptom management that they were in before the treatment. These individuals find themselves back in an orthotic to control pain and locking, experience severe pain flare-ups several times per year, and require regular physical therapy, chiropractic adjustments, or massage therapy in just to maintain the most basic levels of function.

There are certainly circumstances where TMJ surgery may be the only answer, but those cases are extremely rare and usually involve some sort of trauma. The most successful case of TMJ surgery I have ever seen was a surgical unlocking of the discs done on a patient whose discs were displaced through a blow to the chin sustained during a bicycle accident. Again, these cases are the exception rather than the rule. I caution all my patients not to put themselves into the surgery category until all other treatment options have been ruled out or exhausted.

TMJ disorders exist on a broad spectrum of severity, with most cases being transient or easily managed with non-permanent changes to the the teeth or joints. In order to help you better understand this spectrum and the variety of non-surgical treatments available that may be of help, I’ve created a new resource entitled The Benefits of a Non-Surgical Approach to TMJ Dysfunction. I hope you will share this information with anyone you know who suffers with TMJ-related pain and dysfunction. As always, current or prospective patients are always encouraged to call or bring questions about their specific circumstances to their next regularly scheduled appointment.

Martha (Signature)

Jaw Injuries on the Athletic Field

Now that school is back in session and many of our kids are returning to organized athletic activities, it’s time to talk a little bit about jaw injuries on the athletic field. Certainly there is a great deal of information in the news media about concussion and sports-related injuries – especially for heavy contact sports like football and rugby or combat-related athletics like boxing and martial arts. But anytime your child sustains a body hit or blow to the head during a sporting event or physical activity, a tooth or jaw injury may also occur secondary to any other potential injuries to the head and neck.

The most common secondary effect of physical impact on the athletic field is the tendency for the teeth to slam together in reaction to the hit. Even an indirect blow to the body can sometimes force the lower jaw to slam hard enough into the upper jaw that fractured teeth or even a fractured jaw bone may result. A properly-fitted sportsguard is specifically designed to protect your child from these types of injuries. A sportsguard provides a cushion that not only keeps the teeth from slamming into one another, but also holds the joint space a little more open in order to provide some additional protection against a possible fracture in the base of the skull or jaw.

Sportsguards are commonly available in most drugstores and online. It is important that the guard fits your child correctly, and that it is not too big or too small to offer adequate protection. Custom-fabricated sportsguards are also available in our office, and I am always happy to look at an over-the-counter guard to make sure it fits your child properly. But remember, even with a sportsgaurd in place, sometimes injury to your child’s jaw or teeth can still occur.

Whiplash to the jaw is an especially common injury associated with sports-related impact. When your child’s head is thrown off the center of the neck as a result of a direct hit to the head or body, the lower jaw tends to be thrown with equal force in the opposite direction. Just as the muscles and ligaments in the neck can be overstretched into a whiplash injury when this happens, so can the muscles and ligaments of the jaw. A sportsgaurd can be of some protection against a jaw whiplash, particularly if your child’s teeth happen to be resting against it at the moment of impact, reducing the free-swing action of the lower jaw, but not always.

Sometimes a jaw whiplash is fairly minor, resulting in a little soreness in the cheek muscles that resolves within a week or so. Frequently, however, the symptoms of jaw whiplash do not show up until 7 to 10 days after the injuring incident. These symptoms can include jaw pain, headaches, ear pain, and even tooth pain. Your child may not make the connection that these symptoms are possibly related to the fall or hit they took on the athletic field a week or more ago, but you should be on the lookout for them.

A short time in a nightguard or splint to help support the jaw during healing, combined with some massage or physical therapy, may be all your child might need to mitigate the sometimes debilitating pain of a whiplash injury to the jaw. For even more information and some ideas on home care for an injured jaw, please take a look at the newest installment in my ongoing series on headaches entitled Jaw Injuries and Muscle Strain.

As always, I encourage you to call the office with questions or to schedule an appointment to have your child evaluated if you suspect he or she may have a jaw or tooth injury.

Martha (Signature)

Clenching and Grinding

In my 31 years of dental practice, I have seen all kinds of wear and damage to the teeth from a variety of accidents and oral habits. But the most common – and the most damaging – activities seem to be the ones that people are the least aware of. I’m talking about clenching and grinding your teeth, and many people clench and grind far more often than they think they do.

The exact causes for these habits are not known, but we do know that stress is often a contributing factor, and there is some evidence that airway problems and severely misaligned bites may also play a role. But many people who have none of these problems still clench and grind regularly either out of habit or some other cause we don’t yet understand.

The muscles that control your bite can generate huge amounts of force – more force, in fact, than any other muscle system in the body. Certainly, teeth can crack and break under that kind of pressure, and the muscles will often go into spasm and cause all kinds of facial pain. But these immediate symptoms can also be compounded by the slow wearing of the teeth caused by years of unconscious grinding. As the teeth are ground shorter and flatter, the bite collapses. The space that those teeth once held open for the joints and muscles to function properly closes, and chronic pain can set in for many people.

It is always sad for me when I see a new patient who has obviously worn away several millimeters of tooth structure through some kind of long-term grinding habit and seems to be completely unaware of it. “Why didn’t anyone ever tell me this was happening?” is such a common question from new patients in this situation, that I find myself asking the same question: Why aren’t we communicating the importance of this information to our patients more clearly?

Protecting your teeth, muscles, and joints from the wear and tear of an unconscious clenching or grinding habit can be as simple as wearing a nightguard appliance during sleep and becoming more aware of whether or not your teeth are pressed together during the day. Stretching during the day – especially when you notice yourself clenching or grinding – can alleviate muscle spasms, headaches, and help break daytime habits.

If you suspect that you may have a habit of clenching or grinding during the day, or at night – and certainly if you suddenly notice in recent photographs that your teeth just don’t seem to be as tall as they used to be – I encourage you to speak with your dentist about what you can do to protect your teeth from further damage.

There is no question that the best teeth you can have for the rest of your life are the ones you were born with. Anything you can do to protect them from damage and avoid the need to replace them with implants, partials, or dentures will always be worth it for the long-term health of your mouth and your body.

Martha (Signature)

chewing is not optional

For many years before I attended dental school, I worked to support myself and my family as a dental assistant. During that time, I was often fascinated not only with the techniques used to heal disease and repair damage in the mouth, but also with the overall function of the teeth and mouth in general. What made it easy for some people to chew and why was it so painful for others, even when their teeth seemed to fit together?

The dentist I worked for did not treat TMJ disorders, but we certainly saw patients who suffered from the consequences of an unbalanced bite. When the time came for me to go to dental school myself, I was excited to finally learn more about TMJ disorders and the science of occlusion (the bite), in addition to the study of dental technique. I assumed that all three areas of study were a standard part of the dental curriculum. I was wrong.

At school, while I did receive some instruction on occlusion, the majority of my education in that area focused primarily on tooth position with little or no regard for the joints and muscles responsible for the action of chewing. Teeth were teeth. As long as they fit together, everything else was supposed to be fine. But it wasn’t long after I graduated that I encountered my first challenge to this idea.

Shortly after I started in practice, a young woman appeared in my office, crying in pain about her horrible headaches and jaw problems. She could chew, but the pain was greatly exacerbated by the activity. Her doctor’s solution? Stop chewing.

Stop chewing at 28 years old? For how long? The rest of her life? It was ridiculous advice, and even though I didn’t know exactly how to help this young woman at the time, her situation set me on a quest to better understand three-dimensional jaw function that still continues to this day.

There are many often conflicting lines of thought about how the teeth should be aligned, how long the cuspids should be, how sharp the cusps of the teeth should be, and where the “balls” of the lower jaw should fit into the bony concavity in front of the ear. In the more than 30 years since I graduated dental school, I’ve spent countless hours in classes, reading textbooks and journals, and observing the mouth movements and function of my patients. I was, and still am, somewhat obsessed – watching how people move their mouths in movies, in restaurants, and in everyday conversation. I still watch the way the front teeth fit together, study the wear patterns on the teeth, observe the development of crowding – all in an attempt to understand how the entire system functions both in health and in disease.

Early in my quest to understand, and to help this young woman who was now my patient, I came upon the work of Dr. Bernard Jankelson. A noted prosthodontist, Dr. Jankelson had also struggled with the success of bite reconstruction based purely on the mechanics of the teeth. His work, considered by most to be the foundation of neuromuscular dentistry, finally created a system of analyzing jaw movements and bites that also respected muscle function. And I discovered through my study with his son, Dr. Robert Jankelson (a noted prosthodontist himself, and the leading contributor to the promotion and continuation of his father’s work), that the pain my patient was experiencing as a headache was coming from the muscles that couldn’t function correctly while chewing in their current three-dimensional relationship to the teeth.

That young woman I saw so many years ago is still my patient today. And guess what? She’s still chewing. So well, in fact, that sometimes I have to warn her about chewing a little too much gum! The idea of chewing gum when she first came to see me would have been excruciating to her. Today, we’re both grateful that she didn’t just accept the ridiculous advice her doctor initially gave her to simply stop chewing altogether. I wish I could say this is the only time I have heard this advice, but unfortunately the recommendation to stop chewing is still too common. A lifetime of a liquid diet isn’t just boring, it is nutritionally insufficient. In all but the most extreme cases, chewing should never be considered an optional activity.

Martha (Signature)